Statement Of Quarterly Earnings {DWC-40}

CLAIMS-HANDLING ENTITY SENT TO DIVISION DIVISION RECEIVED STATEMENT OF QUARTERLY EARNINGS RECEIVED DATE DATE DATE FOR SUPPLEMENTAL INCOME BENEFITS DATES OF ACCIDENT ON OR AFTER JANUARY 1, 1984 THROUGH SEPTEMBER 30, 2003 FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS COMPENSATION 1-800-342-1741 or contact your local office for assistance PLEASE PRINT OR TYPE  A SOCIAL SECURITY NUMBER EMPLOYEE NAME (First, Middle, Last) DATE OF ACCIDENT:Month-Day-Year) ACCIDENT EMPLOYER NAME FILING PERIOD: ___________________________________ THROUGH ___________________________________ BEGINNING DATE ENDING DATE B NOTICE TO EMPLOYEE: Report all wages earned duri ng the filing period in the area provided below. PLEASE CHECK APPROPRIATE BOXES: *** See instructions on the back side of this form *** I RETURNED TO WORK BUT MY REDUCED WAGES WERE A DIRECT RESULT OF MY IM PAIRMENT FROM THIS INJURY. DURING ANY WEEKS I WAS NOT EMPLOYED , I HAVE IN GOOD FAITH ATTEMPTED TO OBTA IN EMPLOYMENT, WHICH I AM ABLE TO DO. Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information commits insurance fraud, punishable as provided in s. 817.234. Section 440.105(7), F.S. I HAVE REVIEWED, UNDERSTAND, AND ACKNOWLEDGE THAT THE INFORMATION PROVIDED ON THIS FORM AND ANY ATTACHMENTS IS TRUE AND CORRECT . EMPLOYEE SIGNATURE: _____________________________________________________________________________________________ DATE: _________________________________ C CURRENT RATE OF PAY: $ _______________PER HR WK DAY MO GRATUITIES AS (CLAIMS- FRINGE BENEFITS (employee recd) REPORTED TO HANDLING HOURS PER DAY ____________ HOURS PER WEEK__________ DAYS PER WEEK __________ THE EMPLOYER ENTITY EMPLOYER COST ONLY WEEK # OF DAYS # OF HOURS IN WRITING AS USE ONLY) WEEK WORKED WORKED GROSS TAXABLE DEEMED HEALTH RENT/ NO. FROM TO THAT WEEK THAT WEEK PAY INCOME WAGES INSURANCE HOUSING 1 2 3 4 5 6 7 8 9 10 11 12 13 AREA BELOW FOR CLAIMS-HANDLING ENTITY USE ONLY 1 2 3 4 5 TOTALS: D MONTHLY SUPP. BENEFITS CALCULATION BENEFIT ADJUSTMENT DUE TO OVERPAYMENT $ Pre-injury AWW x 4.3 x 0.80 = Adjusted Monthly Wage $ Amount Paid for ____/____/____ thru ____/____/____ TOTAL OF Minus (Current AWW x 4.3) = Current Monthly Wage 1+2+3+4+5 $ Paid on ______/______/______ $ Equals Total Monthly Wage Loss $ Amount Due for ____/____/____ thru ____/____/____ $ DIVIDE BY # Multiplied by 0.80 = Monthly S.I.B. Payable Total Amount of Overpayment Credit OF WEEKS IN $ $ EQUALS FILING PERIOD Payment Period Amount of Overpayment Credit applied per month CURRENT $ ________/________/________ thru ________/________/________ (Not to EXCEED 20% of Monthly Payment) $ AVERAGE Subject to Maximum Payable Monthly Adjusted Amount due for WEEKLY at Comp Rate __________ x 4.3 $ ______/______/______ thru ______/______/______ $ WAGE Payment Amount for Initial Remaining Overpayment Credit Month $ $ ADJUSTER NAME: Payment for filing period denied. See attached Notice of Denial. INSURER CODE # DATE PREPARED RETURN THIS FORM TO: CLAIMS-H ANDLING ENTITY NAME, ADDRESS AND TELEPHONE# SERVICE CO/TPA CODE # CLAIMS-HANDLING ENTITY FILE # Form DFS-F2-DWC-40 (08/2004) <<<<<<<<<********>>>>>>>>>>>>> 2 STATEMENT OF QUARTERLY EARNINGS FO R SUPPLEMENTAL INCOME BENEFITS  SOCIAL SECURITY NUMBER EMPLOYEE NAME (First, Middle, Last) DATE OF ACCIDENT: Month-Day-Year) INSTRUCTIONS: (1) Fill out Sections B and C on the front of this form. Use the form that has the first two lines on the front of the form with your name, etc. already completed. List any money you earned during the 13 weeks for the filing period shown on the second line. (2) Attach copies of paycheck stubs, statements from your employer(s), or any other documentation you may have of your earnings during the filing period. (3) If you have no earnings in a particular week, put down $0 for that week. (4) In the boxes below, list all employers you may worked for during the filing period, and the addresses, phone numbers and dates you were employed. (5) Sign and send the completed form to the Insurer or Claims-handling entity name and address noted in the lower right-hand corner on the front of this form. (6) Section 440.15(2), Florida Statutes, requires you to return this form in a timely manner and the failure to return this form may result in a delay in the payment of benefits. A Form DFS-F2-DWC-40, Statement of Quarterly Ea rnings for Supplemental Income Benefits, must be submitted at the end of every three months in order to receive these benefits. NAME OF EMPLOYER(S) DURING THIS FILING PERIOD Employer Employer Employer Date(s) Name Address Phone Employed Form DFS-F2-DWC-40 (08/2004)